Wednesday, 2 January 2008

Osgood-Schlatters Disease or 'Growing Pains'

The most common knee pain for adolescents between 11 and 14.

In response to the excellent observation regarding tendon damage in young people this can be a number of things. Growing Pains, Osgood's Schlatters Disease or Shin Splints. I have extracted some helpful articles from the Internet that will be of interest. They are essentially American articles .

Osgood-Schlatter Disease Kevan E. Ketterling, M.D.

Osgood-Schlatter disease is indeed an impressive sounding ailment. The name brings to mind exotic illness and many patients tend to confuse it with Hodgkin's disease, a form of cancer. In reality, Osgood-Schlatter disease is a very common and benign variety of overuse injury that occurs in knees of adolescents. It is related to growth of the bones and thus occurs only in athletes who have not yet finished growing.

Osgood-Schlatter disease refers to pain, swelling and inflammation about the tibial tubercle. This is the bump on the front of the shin bone (or tibia) where the kneecap tendon (or patellar tendon) attaches. Force from the strong muscles in the front of the thigh is transmitted through this attachment to straighten the knee. The tibial tubercle is also the site of a growth plate. This is an area of cartilage where bone growth occurs. The growth plate cartilage is weaker than the underlying bone and the tendon attached to it.

When the forces across the knee are greater eater than the muscles can accommodate, the growth plate is pulled away from the underlying bone. This results in the pain, swelling and inflammation which characterize the disease. Activity exacerbates the pain, particularly running, kneeling, squatting and jumping. Often pain occurs in both knees. As with other overuse type injuries, symptoms are more common at the beginning of a new season, or after a sudden increase in training intensity.

Osgood-Schlatter disease most commonly occurs between the ages o f 11 and 15, and is more common in boys. This is a time of rapid bone growth, which may contribute to the problem. The bones grow so fast that the muscles and tendons are unable to keep up. This leads to a lack of flexibility and strength, which increases stress on the tibial tubercle.

When an athlete presents with Osgood-Schlatter disease, x-rays are usually necessary to rule out more serious problems such as tumors or infection. Additionally, x-rays may show small extra pieces of bone forming in the patellar tendon where the growth plate cartilage has been pulled away from the underlying bone.

Treatment begins with a short period of rest and methods to reduce the inflammation, such as ice and inflammatory medications. A rehab exercise program is then beg un, emphasizing flexibility and strength, particularly in the quadriceps muscles. A brace which decreases the force on the tibial tubercle is often useful to keep the athlete competing. The goal of treatment is control of the symptoms until growth is finished since once the growth plate has fused to the underlying bone, the problem resolves.

Emphasizing pre-season conditioning can help to prevent development of Osgood-Schlatter disease. Incorporating stretching to increase flexibility into the work-out routine is also important. Lastly, it is important to recognize that in adolescent athletes organized team sports may be only a portion of their overall activity. Gym class, sandlot sports, and even play activities may contribute to overuse injury. 1997-99 Fox Valley Orthopaedic, all rights reserved.

Shin-splints isn't a specific diagnosis,"

reports Dr. Robert Gambrell of the Medical College of Georgia Center for Sports Medicine "It really means that your shins hurt and you don't want to move them. " Shin-splints generally involve pain in the front or inside part of the lower leg. This pain frequently results from tendonitis, the inflammation of the muscles where they attach to the bone," said Dr. Gambrell.

Growing Pains are Real and Common Among Children

By Dr. David Zuckerman

Growing pains. An old wife's tale? Well, yes and no.

Adolescents do experience accelerated growth spurts. And the foot, ankle, and leg pains that young boys - and increasingly girls - report are associated with growth plate centres. Thin, flat, crescent - shaped growth centres separate bone and cartilage in younger children. As a child nears puberty, these growth centres close and ossify, the process by which cartilage becomes bone.

Between the ages of 8 and 12, when boys and girls become more active in sports, or dance, a child may complain of pain or parents may notice limping. While these complaints are historically more common among boys, as more and more girls join in hockey, soccer and other team sports, they, too, suffer growth centre pain. The most common growth centre complaint I treat is severe pain behind the heel, which stems from overusing the foot and ankle in hard training. The fibres of the Achilles tendon pull on the heel's growth plate and create inflammation within the heel bone.

Growth centre pain is even more common among children who have flat feet, toe-in or have other foot problems. For these youngsters, an orthotic, a splint or soft cast is usually enough to properly position and strengthen feet an d ankles, and prevent future pain and injury. With prompt treatment, growth centre pain persists only a few days or weeks and surgery is rarely needed. Untreated, growth centre injury can require long term treatment.

Such an injury can even result in fracture or dislocation of the growth plate, chronic pain, muscle imbalance, reduced range of motion, shortened limbs or permanent joint deformity. In extreme cases, a total joint replacement may be necessary.

When I suspect a youngster's pain is growth plate related, I x-ray the area to rule out fractures or dislocation of the growth plate, which is held together only by cartilage. I examine the child's practice and game schedules, and I often find the youngster is playing sports year-round, practicing daily, warming up with wind sprints and skipping proper cool-down exercise. Kids will resist interrupting their game and practice schedule, even for a short time. But sometimes the podiatrist must immobilize the injured growth centre in a soft removable cast o r splint for a brief period. Then, more often than not, he or she, can prescribe an orthotic for the shoes that allows the child to play, without re-injury.

Usually, when growth centre pain occurs, modifying activity is enough to remedy the problem. Above all, parents and coaches must never allow a youngster to play through injury or pain. The writer is a surgeon podiatrist who practices in Woodbury, NJ.

This is a reprint from the Pulse Section of the Courier Post.

Growing Pains In Children by Bruce A. Epstein, M.D. - 6/8/92

Growing pains are a family common occurrence in a paediatric population. These discomforts are all too familiar to the concerned mother or father who has awoke in the middle of the night to the sound of a crying child. Rushing to the bedside, the parent finds the child holding their leg in obvious pain.

Remarkably, a gentle massage, some hugs, and a few words of reassurance are all that is needed to soothe the pain. The recovery is usually complete by dawn, and the parents are frequently astounded by the sight of their healthy child bouncing out the door at full speed, pain free .

Fitting Shoes to the young Dancer
by Craig Coussins of

Although the foot is such a wonderful piece of natural mechanization we are sometimes apt to forget that it can easily be damaged through incorrect shoe fitting. This can include normal day shoes as well as ballet and other dance shoes.

If we look at three distinct types of dancing , Highland, Irish and Ballet Pointe, all require different physical abilities and use opposing tendons and muscles .The Highland Dancer works on the ball of the foot resulting in a wider width across this area. They can also develop a shorter Achilles Tendon . Great stress is put on to the heads of the metatarsals and the impact can be measured at around three to four times the dancers weight hitting at that point of impact.

The Irish Dancer uses the higher area of the foot including rising up. The action is a more forward travelling movement with impact on the ball of the foot as mentioned in the Highland Dancer. Less pressure is put on the heel.

The Ballet Dancer on Pointe needs muscle extension and strength in the ankle with less emphasis on the metatarsal heads. The weight of the body is supported with the sides of the shoe and not the great toe as some budding ballerinas mothers seem to believe. Not having support on the sides of the shoes can damage the young foot or deform it. The muscle group under the sole is important to allow correct relevè or rising up onto the ball of the foot or base of toes and stress from impact is normally associated I want to discuss the problems to which the Irish dancer is open.

The general observations cover soft shoes for Highland and Irish Dance and hard shoes or Jig shoes for Irish Dance. It is useful to read the results of my day to day work.

Bunions: Deviated toe joints, rolling feet and knock knees.
The most common problem is the bunion and the deviated big toe joint. Bunions. Remember that these are confused with the deviated toe joints, either the outer or inner toe, and inflammation resulting from abrasion or pressure. The solution is to see first of all if the young dancer is rolling in. The great toe will be compensating by twisting to the outside of the foot bringing the great toe joint into play. The area on the surface of the joint will be sore and probably inflamed. This could be inflammation of the Bursa, the small pocket of fluid around the joint but mainly it is the painful callosity on the foot overlaying a projecting bone. The rest of the condition is known as 'halux valgus' or deviated toe joint. The dancer usually needs the toes to be straightened and separated or strapped into the normal line. This can be done if the shape of the foot is spotted at an early stage as young dancers can start this rolling in at age two or three. The teacher can help by checking the foot and making the necessary corrective exercises or send the child to an experienced fitter for further help and advice. It is a good idea to phone the fitter prior to the child's visit if you are particularly concerned about something. I would recommend that you keep a list of child or adult specialist orthopaedic doctors who can improve the condition.

To conclude, the way to avoid bunions is to fit the shoe closely to the foot and make sure that the width is supporting the sides of the foot and that the sides are slightly tight.

Finding solutions:
The dancer sometimes tries to get a larger or wider shoe to allow no pressure and this will result in no support at the sides of the shoe making the foot slip down with the great toe following its line and forcing the joint even further out of alignment exacerbating the original condition. The fact is that a narrower shoe can greatly help the dancer as long as the foot has been strapped into its original line. However depending on how far the condition has developed this may not be possible. I would always work the dancers foot by hand to see how much movement was available and start remedial discussions from there.

The simple fact remains that despite the research made over the last ten years by specialists, some teachers still make young dancers wear the brand of shoe that they as dancers wore when it is quite clear that the foot shapes are so varied and different it is nonsense to assume every foot will fit into the same brand or style of shoe. Especially now that, as a dance shoes designer, I have designed so many new styles, innovations and types of dance shoe to meet the ever growing demands of the art. It is indeed fortunate for many young dancers that their teachers prefer Hullachan as the brand for their students.

If this were the case with the running shoe industry they would be on a losing streak and I am sure that the outdoor shoe manufacturers would never recommend one style of shoe and one shape for every child's foot and that's without taking into consideration the feelings of both child and parent.

To recap the problem we face as teacher, parent, dancer, shoemaker and fitter:
The Arch:

None of these points refer to the dancer as to whether or not they dance, but will help in the fitting.

There are three main shapes of arch, low, medium and high.
Three toe shapes:
The dancer with the low arch may be unable to achieve a satisfactory arch and could have trouble standing on toe or high and even on the ball of the foot. The dancer with the high arch invariably has weak ankles and without proper tuition is unable to support themselves properly as they are simply not pulling up. Using a stiff outer sole will not help.

Exercise to build up strength in the arch will help and wearing the Hullachan will allow better control. If you have no arch wearing the Hullachan will not give you one but if you have any kind of arch shape, the Hullachan will show what you have unlike many other brands. The dancer with the high arch will usually have weak ankles and that will cause her to twist or not get full strength while on half or full toe. This is a problem while learning until the teacher has taught her how to build up her strength and help her to develop the thigh muscles instead of just calf and ankles. As there is no support in the soft toe shoe or pump it is important that good muscle co-ordination is being developed through exercise and centre floor dance technique.

The Toe shapes of dancers:
Three basic shapes of toe perimeter shape will usually determine how a dancer will develop foot strength. This is not how the dancer will develop as a dancer but will indicate possible issues they will need to be aware of with their toe joints and possibly lower limb problems later on. It is worth noting that i the ballet world a dancer is not allowed on pointes or block toe shoes until around three to four years of strengthening development or the toe joints will be seriously damaged and the the knees could also be seriously at great risk. After these training years, the young dancer graduates into pointe shoes which are designed in the shape of an ice cream cone with a squared off toe with the front cone in a stiff shaping, to take some of the weight of the dancer while on their toes.

The Toe Shapes:

The Peasant Foot: The strong foot-This refers to the square foot where the first, second and sometimes third toes are almost the same length. This is a strong foot shape and there is good balance between the first two toes.
The fitting here is usually medium or wide.

The Greek Foot; A long slim foot shape.
This is where we have the longer big or great toe. This is longer than the other four toes.
This could present some problems for some dancers because the toe joint of the great toe is taking all the weight if the dancer is told to go onto their toes. Essentially this means that this dancer will have to work a lot on strengthening their toe joints, arches, ankles and knees to take the weight of their bodies if they choose to go on toes at a later stage.
The fitting here is usually narrow or medium.

The Egyptian Foot: This means either a pointed shape foot.
This is usually where the second toe is longer than the great toe. Now this is only a problem if the shoe is too wide at the toe. The foot makes a natural pointed shape and if the shoe is too wide then there will be space on either side of the toes. However making the shoe too short will pressure the second toe and cause the base of the second toe joint to possibly compress into the the foot and create arthritis later on. Great care needs to be taken ion the fitting of the Egyptian foot.
The fitting here is usually extra narrow or narrow.

General fitting:
Many children today have larger feet than the last generation but not so much fatter feet rather longer slimmer feet. Different areas of the country have predominately different shapes of foot to the other. We have a number of fitting techniques to adapt each shoe to each shape of foot and these alterations are done at the time of fitting. Teachers can also make sure that they check the condition of the young foot and mention any problems quickly to the parent. Often these issues can be observed in how a dancer does a step and whether or not they are able to manage a particular step. Walking on the inside or outside of the feet , Rolling in, sway back legs. knock knees are a quick indications. Other observations are sore backs, sore knees, sore arches. However in very young dancers, the joints are still soft and as you can read from the anatomy section, these joints may not become fully developed until early teens.

An experienced fitter will always point out any problems [or possible problems] to the parent or dancer and this information should be passed on to the teacher for further help. Barrry Kaufax, of Barrys in Scotsdale Arizona and one of Americas leading dance shoe fitters once told me this analogy: It really is vital that the fitter, the dancer and the teacher should work together like a three legged stool. If one leg of that three legged stool stool is not working with the other then something will fall and that is, of course, the dancer. So yes, we all have a responsibility to the trust the young person places in us to do the right thing by them.

Problems when fitting:

The Ingrown toenail:

Starting at any age this condition can result from shoes that are fitted too tight or too short including soft toe ballet, Pointe shoes, Highland or Irish Shoes. The solution to avoid problem conditions is clearly stated in previous paragraphs.
the solution to the condition is to cut the toe nails across the width and not to cut into the sides of the nail or shape the nail into a curve.

Avoiding narrow shoes may be a solution to ingrown Toenails but do not arbitrarily state this as the child may actually benefit from a narrow fitting depending on the where the problem toe is. The great toe is normally the problem one and the condition can be on either side of that toe. You sometimes find the toe is twisted or tight against the next toe and pressure is forcing the skin over the nail. A Podiatrist or chiropodist will give you help in curing the effect but try and avoid the case.

Rolling in or out can also be a cause.

Hammer Toes:

Shoes that are too big when fitted to the child at a young age when the parent wants room for growth and the little foot tries to grip onto the sole of the shoe leading to another condition such as hammer toes as well as ingrown toenails. Another cause is simply tights or socks that are pulled up too tightly and make the toes bend down.

Hand me downs? Second hand Shoes?::
Usually big sisters shoes have been handed down and are still too big. This can also be where a second hand shoe has been bought and previously worn by a completely different shaped foot. So I would never advocate the use of second hand shoes. Why take the risk?

Soft Corns:
In between the toes soft helomas or corns can develop on the dancers foot. Extremely painful this condition can be caused by incorrect shoes as opposed to badly fitting shoes. Warm moist conditions created by Irish or Highland shoes with plastic linings, plastic or P.V.C. insoles etc]. Hullachan do not use plastic materials to line their shoes. These corns must be professionally looked at and the shoes that create the conditions that lead to butyric acid formation through excess perspiration must be avoided. After all you have 125,000 sweat glands in your foot and it is important that the foot breathes properly. We stopped selling plastic or P.V.C. lined shoes years ago because of the damage they can cause and all our Hullachan products are made with natural materials. The special pad actually breathes and allows air to duct.

Hard Corns:
Common among dancers that had their shoes fitted incorrectly usually form on the knuckles of the second third and fourth toes. We can talk about this effect and the causes for a long time but the salient causes go back to two major situations we discussed in the other articles on my website first is when you ask a dancer to point their toes, unless you actually check them they invariably point their big toe and curl their other toes.

As a fitter I see this with the young Highland and, sometimes, Irish Dancer.

When the foot is young the cartilage has not hardened and the young foot can stay in this shape. The problem of course is that the foot is not being stretched and the development of the arch will never be easy but the knuckles of the foot are raised to the top of the shoe and through abrasion and pressure a callosity will grow on the head of the joint and a corn could form. The point about the shoe being too big for the young foot and a hammer toe condition developing can also apply to this problem. The other cause is when a shoe is too big or too wide and the dancer slides down into the crown of the shoe and finishes up being supported not by the sides of the shoe but by her bent toe joints in the tip of the shoe. More common than you would believe this is caused by the shop that sells only a few assorted sizes of shoe and tries to sell what they, the shop, have rather than what the dancer should have. Unfortunately there are a few bad fitters still around and you, as teachers, parents and dancers must determine the professionalism of the shop you are recommending your students to.

We all know that the job of teaching doesn't finish when the pupil leaves the class and as the young dancer looks to you for advice in dance they also rely on you to advise them as to the correct shoe and the correct fitter.

Achilles Tendonitis:
Achilles Tendonitis can be caused by a number of problems and most of these are easily solved. The first is where the drawstring has been pulled too tight and is digging into the back of the ankle creating pressure on the sheath of the tendon and causing inflammation. One of the results of this is the so called heel bump and the problem of that is the dancer can never get a shoe to fit comfortably either for dance or for street wear.

Another cause is faulty technique in landing and taking off when performing a jetè or jump. In both cases this may be the result of the shoe being too big and the drawstring being pulled too tight to compensate. This also goes back to the dancer who has developed the width of the met heads through Highland or because of a bunion or deviated toe joint. In all these cases the heel will not widen to match the width at the front of the foot. This causes the heel of the shoe to be too loose. In this case we can in some cases alter the heel shape to make the shoe a little firmer.

I would like to help with any questions that you may wish to ask about shoes, fitting or problems so please send your comments or questions, anonymously if you wish and I will be delighted to assist teachers and parents.

Teachers are welcome to use, copy or distribute these articles on condition that all articles are marked copyright © Craig, and that reprinting and distribution is not for profit. All other articles must be marked with the authors name and copyright. These articles are for the benefit of our kids health and similar information should be made available to increase our knowledge of these matters.

Interesting link to a toe care range of protectors:

Doctors, Podiatrist and Medical Advice: Anything you have read here refers to my own experience and it is important that if you have any issues you must take the dancer to a specialist in any event. The notes here are to give you some general information. The Doctor and specialist can often help alleviate the condition but as as fitters, teachers, parents and dancers, we need to try and work out the cause if the cause has come about from the dance or shoe.

1 comment:

marrog said...

My ten year old daughter dances three times a week and has an unsightly lump protruding from the outer sides of her feet , I only noticed this three weeks ago. She apparently was not telling me it was painful till she cried when we went shopping last week because of the pain when walking. The lumps protrude out from the sides of her feet like a pointy bump very painful to touch ,red about half way between her small toe and side of heel .the hospital doctor diagnosed osgood schlatter or traction epiphyseal injury and told the bumps will stay and to give her anti inflammatories till she doesn't complain of pain. Is this what it sounds like to you ? I have to wrap both feet up for school because it feels better for her and painkillers three times a day , no more dancing either ,she's very upset what else can I do we have no future outcomes for this as doc has taken such little interest in any cure but more excited she made a diagnosis via xray